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浙江大学学报（医学版）
浙江大学学报（医学版）  2019, Vol. 48 Issue (5): 533-539    DOI: 10.3785/j.issn.1008-9292.2019.10.11
原著     
经皮腔内血管成形术结合药物溶栓治疗动静脉内瘘急性血栓形成的疗效观察
张树超(),祝成,叶有新,李华*()
浙江大学医学院附属邵逸夫医院肾内科 血液透析血管通路中心, 浙江 杭州 310016
Percutaneous transluminal angioplasty combined with thrombolysis for acute thrombosis in arterio-venous fistula and graft
ZHANG Shuchao(),ZHU Cheng,YE Youxin,LI Hua*()
Department of Nephrology, Center of Vascular Access for Hemodialysis, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
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摘要：

目的: 探讨超声或放射监测下经皮腔内血管成型术结合药物溶栓治疗血液透析动静脉内瘘急性血栓形成的效果。方法: 选取2014年10月至2017年10月浙江大学医学院附属邵逸夫医院动静脉内瘘血管经过物理和影像学检查证实存在血栓形成和血流停滞的患者192例，血栓形成时间一般不超过72 h，排除活动性出血、严重凝血功能障碍等溶栓及手术治疗禁忌患者。在超声或放射监测下，采用尿激酶和肝素等渗氯化钠混合液溶栓，狭窄部位行球囊扩张术，使内瘘血流再通并恢复功能。结果: 2014年10月至2017年10月共192例患者施行了274例次内瘘血管急性血栓形成的腔内介入手术，技术成功率为98.2%，临床成功率为93.8%，并发症发生率1.46%。自体动静脉内瘘患者术后3、6、12个月的初级通畅率分别为87.4%、76.7%、63.9%，次级通畅率分别为93.7%、91.6%、83.0%；移植血管动静脉内瘘患者术后3、6、12个月的初级通畅率分别为60.7%、51.5%、43.1%，次级通畅率分别为82.7%、77.1%、70.8%。结论: 腔内介入技术结合药物溶栓是治疗动静脉内瘘急性血栓形成安全、有效的方法，能够延长内瘘的使用寿命，保护患者宝贵的血管资源。
关键词： 动静脉瘘/并发症;  血管/移植;  血管成形术, 气囊, 冠状动脉;  血栓溶解疗法;  血栓形成/治疗;  尿激酶型纤溶酶原激活物/治疗应用;  导管, 留置    
Abstract:

Objective: To evaluate the efficacy of ultrasound or fluoroscopic-guided percutaneous transluminal angioplasty (PTA) combined with thrombolysis for the treatment of acutely thrombosed arteriovenous fistula (AVF) or grafts (AVG). Methods: One hundred and ninety-two hemodialysed patients, in whom the thrombosed arterio-venous AVF or AVG developed less than 72 h and there were no contraindications for thrombolysis and PTA, underwent PTA combined with thrombolysis therapy in Sir Run Run Shaw Hospital of Zhejiang University from October 2014 to October 2017. Under ultrasound and/or fluoroscopic guidance, balloon catheter was introduced to thrombosis sites along a guide wire. Then the balloon was inflated and normal saline mixed with urokinase and heparin was injected for thrombolysis. After blood flow was restored, angioplasty was performed on vascular stenosed sites. Results: A total of 274 endovascular interventional operations were performed for 192 patients. The procedure success rate was 98.2%, clinical success rate was 93.8%and complication rate was 1.46%. The post-intervention primary patency rates for AVF group were 87.4%, 76.7%and 63.9%at 3, 6 and 12 months, respectively; while the post-intervention secondary patency rates were 93.7%, 91.6%and 83.0%, respectively. The post-intervention primary patency rates for AVG group were 60.7%, 51.5%and 43.1%at 3, 6 and 12 months, while the post-intervention secondary patency rates were 82.7%, 77.1%and 70.8%, respectively. Conclusion: PTA combined with thrombolysis is an effective and safe therapeutic option for AVF and AVG thrombosis, which would prolong hemodialysis access and save vascular resources for hemodialyzed patients.
Key words: Arteriovenous fistula/complications    Blood vessels/transplantation    Angioplasty, balloon, coronary    Thrombolytic therapy    Thrombosis/therapy    Urokinase-type plasminogen activator/ therapeutic use    Catheters, indwelling
收稿日期: 2019-04-05 出版日期: 2020-01-04
:  R459.5  
基金资助: 浙江省自然科学基金(H0508-Y15H050011, H0503-Q15H05001)
通讯作者: 李华     E-mail: 3411003@zju.edu.cn;h_li@zju.edu.cn
作者简介: 张树超(1985-), 男, 硕士, 住院医师, 主要从事急慢性肾脏病的诊治、终末期肾脏病的血液净化治疗、血液透析血管通路的建立和维护; E-mail:3411003@zju.edu.cn; https://orcid.org/0000-0001-7652-137X
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引用本文:

张树超,祝成,叶有新,李华. 经皮腔内血管成形术结合药物溶栓治疗动静脉内瘘急性血栓形成的疗效观察[J]. 浙江大学学报（医学版）, 2019, 48(5): 533-539.

ZHANG Shuchao,ZHU Cheng,YE Youxin,LI Hua. Percutaneous transluminal angioplasty combined with thrombolysis for acute thrombosis in arterio-venous fistula and graft. J Zhejiang Univ (Med Sci), 2019, 48(5): 533-539.

链接本文:

http://www.zjujournals.com/med/CN/10.3785/j.issn.1008-9292.2019.10.11    或    http://www.zjujournals.com/med/CN/Y2019/V48/I5/533

图 1  经皮腔内血管成形术结合药物溶栓治疗过程的超声影像
狭窄部位治疗前治疗后t值P值
AVF：自体动静脉内瘘；AVG：移植血管动静脉内瘘.
AVF吻合口1.75±0.804.05±1.285.337< 0.01
AVF动脉(流入道)1.62±0.483.65±0.446.135< 0.01
AVF静脉(流出道)1.79±0.573.88±0.7916.255< 0.01
AVG动脉吻合口2.30±0.744.23±0.8016.798< 0.01
AVG静脉吻合口2.19±0.924.46±0.8219.345< 0.01
AVG动脉(流入道)2.73±0.584.62±0.797.364< 0.01
AVG静脉(流出道)2.29±0.934.37±0.8225.235< 0.01
移植血管2.62±0.554.64±0.8015.027< 0.01
表 1  192例内瘘患者治疗前后狭窄血管内径比较
图 2  经皮腔内血管成形术结合药物溶栓治疗后自体动静脉内瘘和移植血管动静脉内瘘的通畅率
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